Job Title: Care Management Coordinator (Home Health) Department: Care Management & Coordination Location: 100% Remote License Required: Active Pennsylvania (PA) RN License Job Summary We are seeking a Care Management Coordinator (RN) to support our Home Health team. In this role, you will review medical records and evaluate clinical conditions to determine the medical necessity of healthcare services. You will apply clinical expertise, critical thinking, and established guidelines to authorize appropriate care and ensure compliance with regulatory standards. This position involves collaboration with providers, case managers, and medical directors to ensure members receive the right level of care while navigating the healthcare system effectively.

Key Responsibilities

• Review medical records and assess clinical conditions to determine medical necessity of services
• Apply clinical guidelines such as InterQual and internal medical policies for decision-making
• Authorize medically necessary services independently (approval authority only; no denial authority)
• Communicate with providers to obtain or clarify clinical information and treatment plans
• Refer cases not meeting criteria to the Medical Director for further review
• Evaluate inpatient admissions, continued stays, and discharge planning needs
• Collaborate with care teams to ensure appropriate level of care and smooth transitions
• Identify utilization trends, gaps in care, and recommend improvements
• Ensure compliance with federal, state, and accreditation regulations
• Maintain accurate and timely documentation in system records
• Meet productivity and turnaround time goals for case reviews

Required Qualifications

• Active PA RN License (Required)
• Strong clinical knowledge with experience in utilization review, care management, or case management
• Experience using InterQual or similar medical necessity criteria (preferred)
• Excellent critical thinking, analytical, and decision-making skills
• Strong communication skills with ability to interact with providers and care teams

Preferred Experience

• Home Health or Managed Care experience
• Prior experience in utilization management (UM) or care coordination
• Familiarity with discharge planning and transitions of care

Regards, Abhishek Kumar Senior Recruiter [email protected] 732 351 4075